The client with a moderate to large pericardial effusion is at risk for the development of cardiac

tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, narrowed pulse
pressure, jugular venous distension, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. The nurse
should report these findings to the health care provider immediately and prepare for a pericardiocentesis.

Following repair of an abdominal aortic aneurysm, hemodynamic stability is a priority. Prolonged

hypotension can lead to graft thrombosis. A falling blood pressure and rising pulse rate can also signify
graft leakage

Radiofrequency catheter ablation is a cardiac catheterization procedure indicated for a client with
recurrent episodes of supraventricular tachycardia. After cardiac catheterization, the client must remain
supine with the head of the bed at ≤30 degrees and the affected extremity straight to prevent bleeding
from the catheter insertion site.

Difficulty swallowing is the most important symptom to report to the HCP. A thoracic aortic aneurysm
can put pressure on the esophagus and cause dysphagia. The development of this symptom may indicate
that the aneurysm has increased in size and may need further diagnostic evaluation and treatment.

Elevation of BNP to >100 pg/mL is seen in heart failure. It aids in the assessment of the severity of heart
failure and helps distinguish cardiac from respiratory causes of dyspnea.

An inferior vena cava filter traps thrombi migrating from the lower extremities to the lungs. Discharge
teaching includes promotion of physical exercise, reporting of symptoms of pulmonary embolism (eg,
chest pain, shortness of breath) and impaired lower extremity circulation (eg, pain, numbness), and
notification of the health care team prior to MRI.
Clients with cardiomyopathy may develop cardiogenic shock due to the heart's inability to circulate blood
effectively, causing reduced cardiac output. Treatment of cardiogenic shock includes supplemental
oxygen, an ECG, cardiac enzyme testing, and interventions to reduce cardiac workload.
An atrioventricular pacemaker (also known as a sequential or dual chamber pacemaker) paces the right
atrium and right ventricle in sequence. The ECG will have 2 pacer spikes, one before the P wave and
one before the QRS complex. The P wave following the atrial pacer spike may be normal or abnormal
appearing. The QRS complex following the ventricular pacer spike is typically wide and distorted. An
atrioventricular pacemaker can improve synchrony between the atria and ventricles. It may be implanted
in the client with bradycardia, heart block, or cardiomyopathy.

An atrial paced rhythm would have a pacer spike before the P wave only. The P wave may appear normal
or abnormal; the QRS complex will appear normal.

Biventricular pacemakers (also known as sequential biventricular pacemakers) generate impulses in both
ventricles. Two ventricular pacing spikes may be seen on the ECG, and one spike may appear after the
beginning of the QRS complex.

A ventricular paced rhythm would only have a pacer spike prior to a wide QRS complex. Impulses are
generated in only one ventricle (typically the right ventricle).
PVCs are wide and distorted and occur early in the underlying rhythm. They are usually not harmful in
the client with a healthy heart. PVCs in the client with myocardial infarction indicate ventricular
irritability and should be assessed immediately.

The nurse should carefully monitor renal status in a client who has had abdominal aortic aneurysm repair.
BUN, creatinine, and urine output should be assessed. Urine output of at least 30 mL/hr is expected.
Ventricular fibrillation (VF) is a lethal arrhythmia characterized by disorganized electrical activity in
the heart ventricles. Because of this erratic electrical activity, the heart's muscles lose the ability to
contract, resulting in loss of blood flow and pulse (eg, cardiac arrest). Nurses who identify a client with
VF should immediately check the pulse, start CPR, and prepare the client for defibrillation.

Key risk factors for developing hypertension include African American ethnicity, increasing age, positive
family history, smoking, excessive sodium and alcohol use, diabetes mellitus, obesity, hyperlipidemia,
chronic stress, and sedentary lifestyle. Untreated hypertension increases client risk for coronary artery
disease, stroke, heart failure, and renal failure.

Third-degree AV block results in dissociation of atrial and ventricular contraction due to blocked
electrical conduction pathways. Temporary or permanent pacing is necessary to stabilize the client.

An aneurysm is an outpouching or dilation of a vessel wall. An abdominal aneurysm occurs on the aorta.
A bruit, a swishing or buzzing sound that indicates turbulent blood flow in the aneurysm, is best heard
with the bell of the stethoscope. It may be auscultated over the aortic aneurysm in the periumbilical or
epigastric area slightly left of the midline.
A pedal pulse decreased from baseline or an absent pedal pulse and a cool or mottled extremity in a client
who is postoperative abdominal aortic aneurysm repair can indicate the presence of an arterial or graft
occlusion and poses the greatest threat to survival.

Clients with pericardial effusion should be monitored and assessed closely for the development of cardiac
tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, hypotension,
narrowed pulse pressure, jugular venous distension, and pulsus paradoxus.

Pericarditis is characterized by typical pleuritic chest pain that is sharp. It is aggravated during
inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. Treatment
includes a combination of NSAIDs or aspirin plus colchicine.

In peripheral artery disease, arteries in the extremities become atherosclerotic (progressive thickening and
hardening due to chronic damage). Peripheral tissue perfusion is impaired, causing pain with exercise
(eg, intermittent claudication) and at rest. Risk factors include hypertension, diabetes mellitus,
hyperlipidemia, and smoking.

The nurse needs to monitor groin puncture sites, peripheral pulses, urine output, and kidney function in
the client who has had minimally invasive endovascular repair of an abdominal aneurysm.

Synchronized cardioversion is a cardiac procedure used to convert tachyarrhythmias with a pulse to stable
cardiac rhythms. Nurses preparing to perform cardioversion must verify that the defibrillator's "sync"
feature is engaged to prevent delivery of an asynchronous shock, which may cause life-threatening
arrhythmias.

A deep venous thrombosis (DVT) is a blood clot formed in large veins, typically of the lower extremities,
that occurs commonly from decreased activity or mobility. Clinical manifestations of a lower-extremity
DVT include unilateral edema, calf pain or tenderness to touch, warmth, erythema, and low-grade fever.

The client with symptomatic bradycardia should be treated initially with IV atropine. Transcutaneous
pacing or infusion of dopamine or epinephrine may be considered if atropine is ineffective.

Cardiac tamponade is a possible complication of acute pericarditis that impairs cardiac output and is
life-threatening without immediate intervention. Clinical features of cardiac tamponade include
hypotension, muffled heart sounds, and neck vein distension (Beck triad)

In the presence of acute decompensated heart failure (ADHF) and pulmonary edema, diuretic (eg,
furosemide) administration is effective in removing excess fluid to reduce pulmonary congestion and
improve oxygenation. Vasodilators (eg, nitroglycerin, nesiritide) and positive inotropes (eg, dopamine,
dobutamine) are also used in the treatment of ADHF.
The Dietary Approaches to Stop Hypertension (DASH) diet is often recommended to reduce blood
pressure in clients with hypertension. The client is taught to limit intake of sugar, sodium, cholesterol,
and trans or saturated fats, and instead choose healthier options (eg, fresh fruit and vegetables, low-fat
dairy products).

The nurse should instruct the client with peripheral arterial disease to never apply direct heat to
extremities due to the risk of a burn from decreased sensitivity. Additional teaching for the client with
PAD includes the following:

● Smoking cessation
● Regular exercise
● Achieving or maintaining ideal body weight
● Low-sodium diet
● Tight glucose control in diabetics
● Tight blood pressure control
● Use of lipid management medications
● Use of antiplatelet medications
● Proper limb and foot care
For clients with a newly implanted permanent pacemaker, the nurse should assess for electrical capture of
heart rhythm (eg, ECG) and mechanical capture of heart rate (eg, pulse). A central pulse (eg, auscultation
of apical, palpation of femoral) should be assessed to determine mechanical capture.

Cardiac catheterization involves injection of IV iodinated contrast to assess for obstructed coronary
arteries.

Potential complications of IV iodinated contrast include:

● Allergic reaction: Clients with a previous allergic reaction to iodinated contrast may require
premedication (eg, corticosteroids, antihistamines) to prevent reaction or an alternative contrast
medium
● Lactic acidosis: When administered to clients taking metformin, IV iodinated contrast can cause
an accumulation of metformin in the bloodstream, which can result in lactic acidosis. Therefore,
health care providers may discontinue metformin 24-48 hours before administration of contrast
and restart the medication after 48 hours, when stable renal function is confirmed
● Contrast-induced nephropathy: Iodinated contrast can cause acute kidney injury in clients
with renal impairment (eg, serum creatinine >1.3 mg/dL [115 µmol/L]). Therefore, clients with
renal impairment should not receive iodinated contrast unless absolutely necessary

Clients with permanent pacemakers should carry a pacemaker identification card, wear a medical alert
bracelet, avoid MRI scans, avoid placing a cell phone over the pacemaker, and inform airport security
personnel. Above-the-shoulder exercises should be avoided on the side of the pacemaker until cleared by
the health care provider. Microwave ovens are safe to use.

Signs of graft leakage that are important to monitor after repair of an abdominal aortic aneurysm include
pain in the back, pelvis, or groin; ecchymosis of the groin, scrotum, or penis; tachycardia; weak or absent
peripheral pulses; decreasing hematocrit and hemoglobin; increased abdominal girth; and decreased
urinary output.

A major problem with long-term management of hypertension is poor adherence to the treatment plan.
The nurse should teach the client the importance of taking blood pressure medications as prescribed.

The pulses in the neck should be palpated for information on arterial blood flow. The carotid arteries
should be palpated separately to avoid vagal stimulation causing dysrhythmias such as bradycardia or a
syncopal episode. Pulse symmetry for other key arteries (eg, temporal, brachial, radial, posterior tibial) is
assessed by bilaterally palpating each pair simultaneously.

The nurse caring for a client with intermittent claudication from PAD should assess the adequacy of
circulation to the extremities by palpating and assessing the quality of posterior tibial and dorsalis pedis
pulses. The quality of circulation will guide the treatment plan including risk factor modification, drug
therapy, and possible surgical revascularization.
Occasional premature ventricular complexes are common dysrhythmias and usually do not cause
hemodynamic instability. Clients with atrial fibrillation and rapid ventricular response, complete heart
block, or other threats to cardiovascular stability require continuous observation in the intensive care unit.

The nurse should instruct the client with a Holter monitor to keep a diary of activities and any symptoms
that occur while wearing it. The client should also be taught not to bathe during the testing period but to
continue all other normal activities.

Assessing the function of a new permanent pacemaker is a priority after operative placement. The nurse
should immediately attach the cardiac monitor before making other appropriate assessments.

Open aneurysm repair involves a large abdominal incision and requires cross-clamping the aorta
proximally and distally to the aneurysm. Establishing baseline data is essential for comparison with
postoperative assessments. The nurse should pay special attention to the character and quality of
peripheral pulses and renal and neurologic status. Dorsalis pedis and posterior tibial pulse sites should be
marked for easy location postoperatively. A decreased or absent pulse with cool, pale, mottled, or painful
extremity postoperatively can indicate embolization or graft occlusion. Graft occlusion may require
reoperation.

Air embolism is a rare, life-threatening complication of central venous catheter (CVC) insertion/removal.
Nurses caring for clients with symptoms of air embolism after CVC removal should apply an occlusive
dressing to the site, administer oxygen, position the client in left lateral Trendelenburg position, monitor
client status, and immediately notify the health care provider.

Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial
fibrillation, bradycardia, heart blocks).

Sexual counseling is important for cardiac clients, yet can be difficult for clients and HCPs to discuss and
is often neglected. Clients' concern about resumption of sexual activity can prove to be more stressful
than would be the activity itself. The nurse should encourage clients to discuss concerns with the HCP; in
general, if a client can walk 1 block or climb 2 flights of stairs without symptoms, the client can resume
sexual activity safely.
A marked decrease in mediastinal chest tube drainage warrants immediate assessment for signs of cardiac
tamponade (eg, muffled heart tones, pulsus paradoxus, hypotension). If there are no signs of tamponade,
the nurse should troubleshoot other possible causes of chest tube occlusion and contact the health care
provider.

The client being discharged with heart failure should receive teaching related to weight monitoring, diet,
medication regimen, activity, and symptoms to report.

Map is equal too...Systolic Blood Pressure + (Diastolic Blood Pressure × 2)

3
Signs and symptoms of a failing pacemaker include failure to capture (pacer spikes without associated
QRS complexes) with bradycardia and hypotension. The nurse should use a transcutaneous pacemaker to
stabilize the client until the internal pacemaker can be repaired or replaced.

Discharge education for the client with chronic heart failure should include daily weights, drug regimens,
diet, and exercise plans. The use of any NSAIDS is contraindicated in heart failure as these contribute to
sodium retention, and therefore fluid retention.

In endocarditis, the vegetations over the valves can break off and embolize various organs, resulting in
life-threatening complications. These include the following:

1. Stroke - paralysis on one side

2. Spinal cord ischemia - paralysis of both legs
 3. Ischemia to the extremities - pain, pallor, and cold foot or arm
4. Intestinal infarction - abdominal pain
5. Splenic infarction - left upper-quadrant pain

The pain of peripheral artery disease is arterial in nature and results from decreased blood flow to the legs.
It is made worse with leg elevation. Arterial ulcers are formed at the most distal end of the body. Venous
ulcers form over the medial malleolus, and compression bandaging is needed to reduce the pressure.

Signs of adequate hydration are normal urine specific gravity (1.003 to 1.030), adequate volume of urine
output (>30 mL/hr), and capillary refill of less than 3 seconds. Pulse pressure narrows in shock, and
positive orthostatic vital signs (decreasing systolic blood pressure and rising heart rate) with position
change indicate dehydration.

Acute-onset dyspnea and cough with frothy, pink-tinged sputum indicate pulmonary edema. Auscultation
reveals crackles at the lung bases.

Clients on the organ donation waiting list are educated regarding strict compliance with
immunosuppressive therapy, which requires a lifelong commitment to prevent acute transplanted organ
rejection.
A drop in systolic BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg, or experiencing lightheadedness
or dizziness is considered abnormal

Murmurs are produced by turbulent blood flow across diseased or malformed cardiac valves. They can be
characterized as musical, blowing, swooshing, or rasping sounds heard between normal heart sounds.
The aortic area is located at the second intercostal space, right sternal border. Murmurs indicate turbulent
blood flow across diseased or malformed cardiac valves. They are often described as musical, blowing,
or swooshing sounds that occur between normal heart sounds. They may be auscultated at the aortic,
pulmonic, tricuspid, or mitral areas.

Absent or decreased volume in the peripheral pulses distal to the graft can indicate compromised
circulation or graft occlusion and should be reported to the health care provider immediately.

Chest drainage >100 mL/hr should be reported to the HCP. Large losses of blood may indicate a
compromise of the surgical suture site and may require repair. The client can quickly become
hemodynamically unstable and may require a return to surgery or transfusion of blood products.

Brain (or b-type) natriuretic peptide (BNP) is secreted in response to ventricular stretch and wall tension
when cardiac filling pressures are elevated. The BNP level is used to differentiate dyspnea of heart
failure from dyspnea of noncardiac etiology. The level of circulating BNP correlates with both severity of
left ventricular filling pressure elevation and mortality.

A normal BNP level is <100 pg/mL [<100 pmol/L]. The nurse would expect a high BNP in a client
exhibiting symptoms of acute decompensated heart failure.

New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent
medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles)
and treatment.

When auscultating for a murmur associated with mitral valve stenosis, the nurse should place the
stethoscope at the 5th intercostal space, midclavicular line.
Distension of jugular neck veins should be performed with the client sitting with the head of the bed at a
30- to 45-degree angle. The nurse will observe for distension and prominent pulsation of the neck veins.
The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid
overload.

Peripheral arterial disease (PAD) is a chronic, atherosclerotic disease caused by buildup of plaque
within the arteries. PAD commonly affects the lower extremities and can lead to tissue necrosis
(gangrene).

Home management instructions for PAD include:

● Lower the extremities below the heart when sitting and lying down - improves arterial blood
flow
 ● Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral
circulation and distal tissue perfusion
● Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin
● Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation
● Stop smoking - prevents vessel spasm and constriction
● Avoid tight clothing and stress - prevents vasoconstriction
● Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents
blood clot development

CVP is a measurement of right ventricular preload (volume within the ventricle at the end of diastole)
and reflects fluid volume problems. The normal CVP is 2-8 mm Hg. An elevated CVP can indicate
right ventricular failure or fluid volume overload.

Clinical signs of fluid volume overload include the following:

● Peripheral edema
● Increased urine output that is dilute
● Acute, rapid weight gain
● Jugular venous distension
● S3 heart sound in adults
● Tachypnea, dyspnea, crackles in lungs
● Bounding peripheral pulses

When administering furosemide, it is important to closely monitor the client's vital signs, serum
electrolytes (potassium), and kidney function tests (blood urea nitrogen, creatinine) prior to administration
to prevent side effects such as hypokalemia, hypotension, and kidney injury.
Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to
the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac
muscle may cause angina, including the following:

● Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of
maximum blood flow to the myocardium)
● Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases
cardiac workload
● Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally
hyperthermia (vasodilation and blood pooling)
● Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide;
nicotine causes vasoconstriction and catecholamine release
● Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction
● Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to
myocardium

The client with heart failure-related fluid overload usually has respiratory symptoms. Assessment of the
client's breathing is the greatest priority. It should be performed before assessment of cardiac rhythm and
interventions such as oxygen and placing an IV for diuretic administration.

Serum cardiac markers are proteins released into the bloodstream from necrotic heart tissue after a
myocardial infarction (MI). Troponin is a highly specific cardiac marker for the detection of MI. It has
greater sensitivity and specificity for myocardial injury than creatine kinase (CK) MB. Serum levels of
troponin increase 4–6 hours after the onset of MI, peak at 10–24 hours, and return to baseline after
10–14 days.

A troponin value of 0.7 ng/mL (0.7 mcg/L) indicates cardiac muscle damage and should be the priority
and immediate focus of the nurse. Normal values: troponin I <0.5 ng/mL (<0.5 mcg/L); troponin T <0.1
ng/mL (<0.1 mcg/L).

Chronic venous insufficiency occurs when the valves in the veins of the lower extremities fail to keep
blood moving forward. Chronic edema and inflammatory changes lead to brownish, thickened skin on
the extremities and venous leg ulcers (commonly on the inside of the ankle).

Venous thromboembolism includes both DVT and pulmonary embolism (PE). DVT is the most common
form and occurs most often (80%) in the proximal deep veins (iliac, femoral) of the lower extremities.
Virchow's triad describes the 3 most common theories behind the pathophysiology of the venous
thrombosis: venous stasis, endothelial damage, and hypercoagulability of blood.

Risk factors associated with DVT formation include the following:

1. Trauma (endothelial injury and venous stasis from immobility)

2. Major surgery (endothelial injury and venous stasis from immobility)
3. Prolonged immobilization (eg, stroke, long travel) causing venous stasis
4. Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior
vena cava)
 5. Oral contraceptives (estrogen is thrombotic)
6. Underlying malignancy (cancer cells release procoagulants)
7. Smoking (produces endothelial damage by inflammation)
8. Old age
9. Obesity and varicose veins (venous stasis)
10. Myeloproliferative disorders (increase blood viscosity)

The PMI is also called the apical pulse. It reflects the pulsation of the apex of the heart and should be felt
medial to the midclavicular line at the 4th or 5th intercostal space. When the PMI is below the 5th
intercostal space or left of the midclavicular line, the heart may be enlarged.

Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that
increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of
polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac
arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation.
The American Heart Association recommends treatment with IV magnesium sulfate.

Posttransplant infection is the most common cause of death due to immunosuppressive therapy. Strict
hand washing and aseptic technique are critical to infection prevention. Symptoms of infection should be
monitored and may include fever >100.4 F (38 C), productive or dry cough, and changes in secretions.

Hypertensive crisis is a life-threatening elevation in blood pressure (systolic ≥180 mm Hg and/or diastolic
≥120 mm Hg) that may cause end-organ damage (eg, stroke, kidney injury, heart failure, papilledema).
The client's level of consciousness should be monitored, as a decreased level may indicate onset of
hemorrhagic stroke.

The drug of choice in clients with PSVT is adenosine. It is given rapidly via IVP over 1-2 seconds and
followed by a 20-mL saline bolus. An increased dose may be administered 2 more times if previous
administration is ineffective.

This client is experiencing paroxysmal supraventricular tachycardia (PSVT). In PSVT, the heart rate can
be 150-220/min. With prolonged episodes, the client may experience evidence of reduced cardiac output
such as hypotension, palpitations, dyspnea, and angina.

Treatment includes vagal maneuvers such as Valsalva, coughing, and carotid massage. Adenosine is the
drug of choice for PSVT treatment. Due to its very short half-life, adenosine is administered rapidly via
IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose may be given twice if
previous administration is ineffective. Beta blockers, calcium channel blockers, and amiodarone can also
be considered as alternatives. If vagal maneuvers and drug therapy are unsuccessful, synchronized
cardioversion may be used.
Aortic stenosis is the narrowing of the orifice between the left ventricle and aorta. Many clients with
aortic stenosis are asymptomatic. Symptoms usually develop with exertion as the left ventricle cannot
pump enough blood to meet the body's demands due to aortic obstruction (stenosis). These include
dyspnea, angina, and, in severe cases, syncope (reduced blood flow to the brain). Clients usually do not
experience symptoms at rest. Clients with severe aortic stenosis are at risk for developing syncope and
sudden death with exertion. The left ventricle cannot push enough blood into the aorta to meet the body's
demands due to the valve stenosis.

Hypertensive crisis may require continuous infusion of an IV vasodilator. BP should be lowered slowly
to prevent organ damage. The initial goal is to lower MAP by 25% or less or to maintain MAP of
110-115 mm Hg.

The nurse should immediately report the new development of pulmonary congestion on x-ray,
auscultation of a new S3 heart sound, crackles on auscultation of breath sounds, or jugular venous
distension in the post MI client to the HCP. These findings may indicate the development of heart failure
or cardiogenic shock.

Certain individuals should receive prophylactic antibiotics prior to dental procedures to prevent infective
endocarditis (IE). These include the following:

● Prosthetic heart valve or prosthetic material used to repair heart valve

● Previous history of IE
● Some forms of congenital heart disease
○ Unrepaired cyanotic congenital defect
○ Repaired congenital defect with prosthetic material or device for 6 months after
procedure
○ Repaired congenital defect with residual defects at the site or adjacent to the site of a
prosthetic patch or device
 ● Cardiac transplantation recipients who develop heart valve disease

A demand electronic pacemaker should deliver an impulse when it senses an intrinsic pacemaker drop
below a predetermined rate. Bradycardia with failure to capture (pacer spike with no QRS complex)
indicates malfunction and requires immediate notification of the health care provider.

The impaired perfusion from severe atherosclerosis results in skin atrophy, poor wound healing, and
widespread hair follicle death (hair loss).

Clients who are on anticoagulants should avoid aspirin, NSAIDS, and other over-the-counter or herbal
products (eg, Ginkgo biloba) that can increase bleeding risk. They should also avoid behaviors that
increase the risk of clotting (eg, eating excess green leafy vegetables).

Initial interventions in emergency management of chest pain are as follows:

● Assess airway, breathing, and circulation (ABCs)

● Position client upright unless contraindicated
● Apply oxygen, if the client is hypoxic
● Obtain baseline vital signs, including oxygen saturation
● Auscultate heart and lung sounds
● Obtain a 12-lead electrocardiogram (ECG)
● Insert 2-3 large-bore intravenous catheters
● Assess pain using the PQRST method
● Medicate for pain as prescribed (eg, nitroglycerin)
● Initiate continuous electrocardiogram (ECG) monitoring (cardiac monitor)
● Obtain baseline blood work (eg, cardiac markers, serum electrolytes)
● Obtain portable chest x-ray
● Assess for contraindications to antiplatelet and anticoagulant therapy
● Administer aspirin unless contraindicated

If bleeding occurs after cardiac catheterization, the nurse first applies direct manual pressure to control the
bleeding.

This client with a tender calf that feels warm to the touch is exhibiting signs and symptoms of a possible
deep vein thrombosis (DVT). Additionally, the client has several risk factors for DVT (age >60, being
hospitalized and in bed for 3 days). The nurse will need to notify the health care provider (HCP)
immediately. However, prior to this, the nurse must perform a thorough assessment of the client to report
to the HCP.
The presence of an air leak is indicated by continuous bubbling of fluid at the base of the water seal
chamber. If the client has a known pneumothorax, intermittent bubbling would be expected. Once the
lung has re-expanded and the air leak is sealed, the bubbling will cease. The nurse is expected to assess
for the presence or absence of an air leak and to determine whether it originates from the client or the
chest tube system.

● Section A is the suction control chamber. Gentle, continuous bubbling indicates that suction is
present.
● Section B is part of the water seal chamber, but an air leak will not be evident in this upper
portion. Tidaling of fluid is expected in this portion of the chamber and indicates patency of the
tube.
● Section D is the collection chamber, where drainage from the client will accumulate. The nurse
will assess the amount and color of the fluid and record these as output.
Normal adult ABG values at sea level are as follows:

pH 7.35–7.45

PaO2 80–100 mm Hg (10.7-13.3 kPa)

PaCO2 35–45 mm Hg (4.66-5.98)

Bicarbonate (HCO3-) 22–26 mEq/L (22-26 mmol/L)

O2 Saturation (SaO2) 95%–99%

Atrial fibrillation (AF) is a common dysrhythmia after cardiac surgery. It is characterized by a total
disorganization of atrial electrical activity that results in the loss of effective atrial contraction. P
waves are not visible; they are replaced by fibrillatory waves. The ventricular rate varies, but the
rhythm is typically irregular. AF results in decreased cardiac output due to a loss of atrial kick and/or a
rapid ventricular response. Clots may form in the atria, putting the client at increased risk for stroke.

Treatment goals include a decrease in ventricular rate to <100/min and adequate anticoagulation to
prevent thromboembolic complications. Medications used for rate control include calcium channel
blockers (eg, diltiazem, verapamil), beta blockers (eg, metoprolol), and digoxin. Medications that convert
to and maintain sinus rhythm include amiodarone, flecainide, and sotalol. Electrical cardioversion may
also be considered in hemodynamically unstable clients.

Atrial Flutter is characterized by recurring, regular, sawtooth-shaped flutter waves.

Complete heart block has more P waves than QRS complexes, and PR intervals are variable. There is no
communication between the atria and ventricles; each is firing independently of the other.

Second-degree atrioventricular block, type 2 has more P waves than QRS complexes. The PR interval is
constant on conducted beats; it reflects an intermittent block of atrial impulses.

When a client is demonstrating clinical deterioration, the nurse's priority is to prevent full respiratory or
cardiac arrest by calling the rapid response team.

Troponin is a cardiac specific serum marker that is a highly specific indicator of MI and has greater
sensitivity and specificity for myocardial injury than creatine kinase (CK) or CK-MB. Serum levels of
troponin T and I increase 4-6 hours after the onset of MI, peak at 10-24 hours, and return to baseline in
10-14 days. However, MI is not diagnosed alone by serum cardiac markers. Electrocardiogram findings
and client health history along with a history of pain and risk factors are also used to make the diagnosis
of MI.
(VT) is a potentially life-threatening dysrhythmia characterized by a ventricular rate of 100-250/min. The
rhythm is often regular, but it can be irregular. QRS complexes are wider than 0.12 seconds and the P
wave is usually buried in the QRS complex, making a PR interval unmeasurable. Pulseless VT is treated
with cardiopulmonary resuscitation (CPR) and defibrillation.

(VT) is a potentially life-threatening dysrhythmia characterized by a ventricular rate of 100-250/min. The

rhythm is often regular, but it can be irregular. QRS complexes are wider than 0.12 seconds and the P
wave is usually buried in the QRS complex, making a PR interval unmeasurable. Pulseless VT is treated
with cardiopulmonary resuscitation (CPR) and defibrillation.

A premature ventricular contraction (PVC) is a contraction originating from an ectopic foci in the
ventricle. It appears early in the rhythm and has a wide and distorted shape as compared to the underlying
rhythm. A consecutive run of ≥3 PVCs is considered VT.
The rate in sinus tachycardia is 101-200/min and regular. The P wave, PR interval (0.12-0.20 sec), and
QRS complex (<0.12 sec) will be normal. Sinus tachycardia may be caused by hypovolemia,
hypotension, pain, anxiety, stress, or fever. Treatment is based on the underlying cause.

Ventricular fibrillation is characterized on the electrocardiogram by irregular waveforms of varying

shapes and amplitude. It represents the firing of multiple ectopic foci in the ventricle. The client in
ventricular fibrillation will not have a pulse, and defibrillation is essential in addition to CPR under the
ACLS guidelines.

Supraventricular tachycardia (SVT) is a dysrhythmia that originates from an ectopic focus above the
bifurcation of the bundle of His. The heart rate can be 150-220/min. The rhythm is usually regular. P
waves are often hidden. If visible, they may have an abnormal shape and the PR interval may be
shortened. The QRS complex is usually narrow (<0.12 second). Stimulants (eg, nicotine, caffeine,
cocaine) and organic heart disease can cause SVT. Clinical significance depends on the client's
symptoms. A prolonged episode of SVT with a heart rate >180/min will cause decreased cardiac
output and hypotension. The client may also experience palpitations, dyspnea, and angina. Treatment
includes vagal stimulation and drug therapy. Common vagal maneuvers include Valsalva, coughing, and
carotid massage. IV adenosine is the drug of choice to convert SVT to a sinus rhythm. If vagal
stimulation and drug therapy are ineffective and the client becomes hemodynamically unstable,
synchronized cardioversion is used. Recurrent SVT may require radiofrequency catheter ablation.
In atrial fibrillation, P waves are not present, but the rhythm is usually irregularly irregular.

Sinus tachycardia involves a heart rate of 101-200/min but also has a normal P wave preceding each QRS,
with a normal shape and duration. The PR interval is normal (0.10-0.20 second) and the QRS is <0.12
second.

Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in
the ventricle. P waves are usually not visible and are buried in the QRS, and the PR interval is not
measurable. The QRS complex is typically wide (>0.12 second).

Clients with a diagnosis of chronic congestive heart failure experience clinical manifestations of both
right-sided (systemic venous congestion) and left-sided (pulmonary congestion) failure.

Crackles are discontinuous, adventitious lung sounds usually heard on inspiration and indicate the
presence of pulmonary congestion (left-sided failure) in this client. Increased jugular venous distention
reflects an increase in pressure and volume in the systemic circulation, resulting in elevated central
venous pressure (CVP) (right-sided failure) in this client. Although dependent pitting edema of the
extremities can be associated with other conditions (eg, hypoproteinemia, venous insufficiency), it is
related to sodium and fluid retention (right-sided failure) in this client.
Clients with chronic heart failure experience clinical manifestations of both right-sided and left-sided
failure. Therefore, the nurse must be able to assess the clinical manifestations related to systemic volume
increases and pulmonary congestion.

An implantable cardioverter defibrillator (ICD) is a medical device that is surgically implanted

underneath the skin that can sense life-threatening arrhythmia and discharge electrical shocks directly into
the cardiac muscle to correct the arrhythmia. Clients typically receive ICDs after a history of sustained or
recurrent ventricular tachycardia (VT), including personal or family history of sudden cardiac death and
severe heart failure.

When caring for a client with an ICD, it is critical that the nurse monitor for ICD firings (eg, client report,
observation on cardiac monitors). After firings, the nurse should monitor for resolution of the arrhythmia,
indications of hemodynamic compromise (eg, hypotension, chest pain, altered mentation), and additional
ICD discharges.
Occasionally, an ICD may be unable to convert the arrythmia to a hemodynamically stable rhythm and
will repeatedly shock the client. If the client experiences repeated ICD shocks without dysrhythmia
resolution, the nurse should promptly obtain a manual external defibrillator and initiate measures to
prevent hemodynamic instability and cardiac arrest

The synchronizer switch must be turned on when cardioversion is planned. The synchronize circuit in
the defibrillator is programmed to deliver a shock on the R wave of the QRS complex on the
electrocardiogram (ECG). This allows the unit to sense this client's rhythm and time the shock to avoid
having it occur during the T wave. A shock delivered during the T wave could cause this client to go into
a more lethal rhythm (eg, ventricular tachycardia, ventricular fibrillation). If this client becomes
pulseless, the synchronize function should be turned off and the nurse should proceed with
defibrillation.

Synchronized cardioversion is indicated for ventricular tachycardia with a pulse, supraventricular

tachycardia, and atrial fibrillation with a rapid ventricular response.

The tell-tale symptom of bladder cancer, seen in >75% of cases, is painless hematuria; the client will
report seeing blood in the urine with no associated pain. As with many other types of cancer, the primary
cause of bladder cancer is cigarette smoking or other tobacco use. Poorer outcomes are seen with
increased length of time as a smoker and higher number of packs per day.

VF is characterized on the ECG by irregular waveforms of varying shapes and amplitudes. This
represents the firing of multiple ectopic foci originating in the ventricle. Mechanically, the ventricle is
quivering with no effective contraction or cardiac output. VF is considered a lethal dysrhythmia. It
results in an unresponsive, pulseless, apneic state. If not treated rapidly, the client will not recover.

VF commonly occurs in acute myocardial infarction and myocardial ischemia and in chronic heart
diseases such as heart failure and cardiac myopathy. It may occur in cardiac pacing or catheterization
procedures due to catheter stimulation of the ventricle.

Treatment consists of rapid initiation of CPR, defibrillation, and the use of drug therapy (eg,
epinephrine, vasopressin, amiodarone).

Right-sided heart failure results from pulmonary hypertension, right ventricular myocardial infarction,
or left-sided heart failure. The right ventricle cannot effectively pump blood to the lungs, which results in
incomplete emptying of the right ventricle. The resulting decrease in forward blood flow causes blood to
back up into the right atrium and then into venous circulation, resulting in venous congestion and
increased venous pressure throughout the systemic circulation. Clinical manifestations of right-sided
heart failure include:

● Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities
● Jugular venous distension
● Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg,
hepatomegaly, splenomegaly) and ascites. Nausea and anorexia may also occur as a result of
increased abdominal pressure and decreased gastrointestinal circulation.
● Hepatomegaly due to hepatic venous congestion.
Paracentesis is a procedure that involves removal of excess fluid from the peritoneal cavity (ascites) and
is performed to relieve dyspnea and discomfort related to increased intra-abdominal pressure and fluid
volume. Hypovolemia is an associated complication related to intravascular fluid shifts that occur during
and post-procedure and also to high volume peritoneal fluid removal (>5 L). The nurse should first
validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for
manifestations of hypovolemia (eg, orthostatic hypotension, tachycardia, reduced pulse volume,
decreased urine output), as decreased circulating volume can lead to hemodynamic instability.
Ventricular paced rhythms are seen in clients with ventricular pacemakers. Ventricular pacemakers
typically have one lead placed in the right ventricle. The pacer spike just before the QRS complex
signals electrical stimulation of the ventricle by the pacemaker lead. The pacemaker lead depolarizes the
right ventricle first, and electricity travels across the heart to depolarize the left ventricle. This atypical
electrical pathway distorts and widens the QRS complex. The T wave can be seen immediately after the
wide QRS complex.

Implanted permanent pacemakers are often placed in clients with symptomatic bradycardia or heart block.
Demand pacemakers are the most common type of implanted permanent pacemaker. The demand
pacemaker sends an electrical impulse (pacer spike) only if the pacemaker does not sense an intrinsic
heartbeat occurring at the programmed threshold rate (eg, 40/min).

Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction.
Ventricular tachycardia is characterized by wide QRS complexes occurring at a rate of 150-250/min from
an impulse originating within the ventricle. This rhythm may or may not produce a pulse.

The anatomical location of the phlebostatic axis is the 4th ICS, at the midway point of the AP diameter (½
AP) of the chest wall. The stopcock nearest the transducer is placed here to assure accurate pressure
measurements.